To preserve youthful-looking skin, consider early use of conservative wrinkle-fighting interventions — and the sooner, the better.

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WEDNESDAY, Sept. 18, 2013
(Medpage Today)
— To preserve youthful-looking skin,
consider early use of conservative wrinkle-fighting interventions — and the
sooner, the better, two cosmetic
dermatologists argue in an opinion piece
published online in JAMA Dermatology.

Line patterns that emerge with smiling
during early adulthood foretell the permanent lines and wrinkles that will be
visible without a change in expression
years later. The same is true of sleep
lines.

Given the inevitable progression of line
patterns, it's never "too early" to consider neuromodulators,
fillers, and light or laser treatment, according to
Heather K. Hamilton, MD, and Kenneth A.
Arndt, MD, of SkinCare Physicians in Chestnut Hill, Mass.

"If the action of the muscles of
facial expression is diminished, the lines on the face that are interpreted as
aging, tiredness, or anger will simply not
form," the authors said.
"Initiating regular treatment with a neuromodulator in an individual's 20s
or 30s will have a dramatic effect on the appearance of
the face as seen in the person's 40s or
50s. There will be few, if any, lines of facial expression present."

In stating their case, Hamilton and Arndt
noted that facial lines emerge as a result of repeated folding of the skin
caused by changes in facial expression
and while awake and asleep. Repeated
contraction of muscles involved in facial expressions eventually causes frown
lines, forehead lines, and crow's feet.

As a case in point, they cited a report
about 38-year-old identical twin sisters. One twin started regular injections
of botulinum toxin in the forehead
and glabella at age 25, and the other
received injections in the same areas twice over 7 years.

Side-by-side comparison of the two showed
visible forehead and glabella lines in the sister who had only a few treatments
and no lines at all in the sister
who began regular treatment at an early
age.

Some of the anti-aging interventions have
biological effects, in addition to physical effects, the authors said, offering
several examples:

Some soft-tissue fillers induce growth of
new connective tissue that has greater durability than the fillers

Studies of hyaluronic acid outside the
field of cosmetic dermatology have shown the substance is involved in cell
signaling, mesenchymal cell migration and
differentiation, and fibroblast
proliferation

Calcium hydroxyapatite has been reported to
induce neocollagenesis, including one study showing a 25 percent increase in
host density of collagen 78 weeks
after injection, suggesting that the need
for re-treatment may diminish or even disappear over time

Intermittent laser and light treatment
induces changes in dermal connective tissue that persist long after the
short-term effects of the energy source.

"Similar to our advocacy for the early
use of other strategies to avoid or diminish the evolution of age-related
changes, such as sunscreens and topical
retinoids, the initiation of conservative
and thoughtful use of neuromodulators, fillers, and noninvasive energy-based
treatments, alone or in combination,
will keep patients looking young and their
skin healthier," Hamilton and Arndt concluded. "So there really is
rarely a time that is too early. Perhaps the
better question is, 'When is it too
late?'"

Responding to a request from MedPage Today,
two other dermatologists generally agreed with Hamilton and Arndt.

"I do believe that you can prevent
wrinkles with a neurotoxin injected regularly to prevent lines by preventing
movement," Rhoda Narins, MD, of New York
University in New York City, said in an
email. "I think most fillers also induce the skin to make collagen simply
by stretching the skin. There have been
articles written on the latter."

"Neurotoxins are used in my practice
for people who have very strong muscle movement, especially in the glabellar
area, with a strong family history of
deep lines," she added. "These
patients are often in their 20s."

David Song, MD, of the University of
Chicago, said early use of neuromodulators and fillers do not necessarily
prevent lines from forming but does address
the immediate issue of strong expression
lines.

"We now have come to appreciate that
these facial lines of expression early in adulthood translate into permanent
lines later on, even at rest," Song said
by email. "So, in essence the
treatment in the young adult of hyperdynamic lines of facial expression has
longer lasting benefits into later adulthood."

However, Song takes issue with the premise
that it's never too early to start treatments. "Of course, doing this in a
[teenager] may be ethically
unsavory," he said.

Narins and Song both see some other
potential downsides to early use of injectable agents, notably the cost
associated with regular treatment over a long
period of time. Narins also noted the
absence of long-term data and the possibility that a patient will look
"over-treated" after a period of time.

"In some patients you can atrophy the
muscles to such a great extent that you have volume loss, and, of course, every
treatment has it's inherent risks and
potential complications," said Song.
"Besides this, the only real downside may be in the pocketbook."

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